BACKGROUND:The IMPULSE trial investigated the effectiveness and implementation of a digital psychosocial intervention (DIALOG+) for people with psychosis in five Southeast European countries. DIALOG+ significantly improved patients' quality of life after four treatment sessions. The process evaluation reported here aimed to assess contextual influences on intervention delivery during the trial, to explain the trial findings and generate hypotheses about mechanisms of action by exploring acceptability from the perspectives of clinicians who delivered it and trial participants who received it, and fidelity (was the intervention delivered and received as planned?). METHOD:A mixed-methods process evaluation was conducted in accordance with the published protocol, guided by theoretical frameworks and the Medical Research Council's guidance for complex interventions. To explore the role of context, data were analysed about the participating services, policy documents, and from focus groups with key stakeholders. Semi-structured interviews with clinicians and patients were conducted to explore acceptability. Process data (format and content of sessions) were analysed to assess intervention fidelity. Data analysis included descriptive methods, framework and content analysis, and triangulation. RESULTS:Several attributes of context related to health services, including resource limitations, funding priorities, reliance on paper records and lack of community support, potentially negatively impacted DIALOG+ acceptability, fidelity and outcomes. Contextual enablers were also identified, including an appetite for change among key stakeholders that can help overcome contextual barriers. Acceptability of the psychosocial intervention was moderate to high and fidelity was high. CONCLUSIONS:Intervention acceptability is likely to have played a key role in ensuring high fidelity, which in turn likely contributed to the intervention's positive impact on patients' quality of life. The high fidelity confirms that the IMPULSE trial findings provide a valid assessment of the intervention as designed. While the identified contextual barriers appear not to have impaired intervention fidelity, acceptability and outcomes, they could pose challenges to the long-term sustainability of the intervention. TRIAL REGISTRATION:Retrospectively registered on 29 March 2021, ISRCTN11913964.

AIM:To demonstrate the application of the Theoretical Domains Framework (TDF) and behaviour change theory to identify behaviour change techniques for a complex intervention targeting dementia care by general practice nurses (GPNs). BACKGROUND:GPNs have an important role in dementia care but require support to translate evidence-based recommendations into routine practice. Theory-informed implementation strategies may help facilitate this change. METHODS:The target behaviour was derived from a Delphi study identifying national dementia care recommendations relevant to GPNs. Barriers to operationalizing the target behaviour were identified from previous research and then coded independently by two authors using the TDF. Identified domains were then mapped to behaviour change techniques using the Theory and Techniques Tool. FINDINGS:The specified behaviour was: 'the general practice nurse will use language that is accurate, respectful, inclusive, empowering and non-stigmatizing when communicating with people living with dementia within each patient encounter in general practice'. Seven TDF domains were identified, including 'knowledge', 'skills' and 'social influences', mapping to 22 behaviour change techniques, including 'instruction on how to perform the behaviour' and 'social support'. This theory-informed approach identifies practical techniques for developing interventions to improve GPN communication with people living with dementia and provides a method that could be applied to other dementia care behaviours in general practice.

Objective: Audit and feedback (A&F) programmes aim to improve patient care by providing summary data on performance to clinicians. They generally have modest, but variable, effects on patient care and questions remain about how best to provide performance feedback. It is not feasible to test all ways of providing feedback in 'real-world' randomised trials. Online screening experiments that screen feedback techniques prior to real-world evaluations of optimised versions offer a systematic approach. User-centred design methodologies can inform the design of such online experiments. Methods: We report the use of an innovative user-centred design approach to create feedback techniques for an online screening experiment and reflect on its usefulness. This approach included the involvement of patients and stakeholders. Results and Conclusion: We highlight lessons on ways to engage with partners, considering the feasibility of online A&F feedback delivery, fidelity, and usability. We demonstrate how the approach was implemented to co-create a set of feedback techniques for an online experiment and could also be applied to the design of other digital interventions.

PURPOSE:To address care gaps in newborn pain management, a parent-targeted video (BSweet2Babies video) was developed using co-design principles. The purpose of the study was to specify which behavior change techniques are included in the BSweet2Babies video and whether they address key barriers to newborn pain management. BACKGROUND:Behavior change techniques are the active components of an implementation intervention and are meant to address barriers in order to increase the impact of the intervention. METHODS:This study adopted a mixed-method approach including 3 phases: (1) identifying behavior change techniques in the BSweet2Babies video, (2) coding parents' barriers for engaging in pain management for their newborn babies based on the theoretical domains framework (TDF), and (3) mapping behavior change techniques to barriers codes. RESULTS:Seven behavior change techniques were identified in the BSweet2Babies video. The key barriers to parents' engagement in newborn pain management were lack of (timely) information about pain management options, parents' difficulty in determining their role in pain management and neonatal intensive care unit environment (lack of space for parents, limited visiting hours). These barriers related to the TDF domains knowledge, social/ professional role and identity and environmental context and resources. The knowledge domain was addressed in the BSweet2Babies video; the other 2 domains were not. CONCLUSIONS:This paper identified potential for additional behavior change techniques that may enhance the BSweet2Babies video. IMPLICATIONS FOR PRACTICE AND RESEARCH:This is an exemplar study of a methodology that could be used to enhance existing implementation interventions.

BACKGROUND:Clear specification of desired behaviour within evidence-based guidelines and policies might make them more actionable, i.e. increase the likelihood that those behaviours will take place in practice. It was our expectation that the level of specificity in such documents would be higher, i.e. more detailed, at the organisational level compared with the national level, given that local documents are developed for a specific setting and workforce. This study aimed to compare infection prevention and control (IPC) behaviours and their specificity in a national guideline with local residential aged care policies and procedures. METHODS:The document analysis was informed by the Action, Actor, Context, Target and Time (AACTT) framework. The Australian Guidelines for the Prevention and Control of Infection in Healthcare and the local policies and procedures of eight residential aged care providers were investigated. RESULTS:There was some overlap between behaviours in the national guideline and local policies and procedures. However, of the 63 behavioural statements in the guideline relating to hand hygiene and appropriate use of gloves and masks, only eight statements were mentioned by all residential aged care providers. Twelve statements were mentioned in the local policies and procedures but not mentioned in the guideline and two statements mentioned locally seemed to conflict with the guideline. IPC statements were generally not well specified in either the national guideline or local documents. CONCLUSION:Local policies and procedures should be more aligned with national guidelines to reflect the evidence base. Once this alignment is in place, attention should be given to increasing the specificity and actionability of these documents.

BackgroundThe provision of healthcare is complex. When evidence-practice gaps are identified, interventions to improve practice across multi-level systems are required. These interventions often consist of multiple interacting components and behaviours. To effectively address these complexities, it is crucial to first identify the specific roles and actions required at each stage of the intervention. This approach enables a thorough examination of what is working well and what needs to be optimised. The action, actor, context, target, time (AACTT) framework provides a consistent approach to identifying key elements such as 'who' (actor) does 'what' (action), 'where' (context), 'to or with whom' (target) and 'when' (time). To our knowledge the AACTT has not yet been applied: 1) to specify complex interventions across patient journeys; and 2) to investigate consumer views, despite the importance of patient-centred care.AimUsing advance care planning (ACP) as an exemplar complex healthcare process, we describe a method for using the AACTT framework to 1) map a complex model of care across a patient journey 2) capture the consumer perspective; and 3) operationalise these perspectives by comparing across groups and identifying alignments or misalignments.MethodsTwo groups were recruited (healthcare professionals and consumers). Informed by the AACTT framework, four focus groups discussed the process of ACP across existing care pathways. Maps visually representing the perspectives and preferences of healthcare professionals and consumers were co-created iteratively. Qualitative data was deductively coded to the AACTT framework and inductively coded to identify themes within domains. Maps were circulated for critical feedback and refined.ResultsHealthcare professional (n-13) and consumer perspectives (n = 11) highlighted what is 'currently occurring' in practice, what is 'not occurring', and what 'should be occurring' to align practice with consumer preferences of care. Comparing participant perspectives identified that most misalignment occurred within the actor, context, and time domains. Misalignment was found predominantly in actions 'occurring sometimes', with no converging perspectives reported for the context and time domains.ConclusionThis novel application of the AACTT framework systematically brings in the consumer voice in ways that may influence the delivery of care. This approach to specifying healthcare professional and consumer perspectives across a complex care pathway identifies barriers that are not found with traditional mapping methods or in current applications of the AACTT framework.

Background Acquired hearing loss has significant negative effects on quality of life, general health, maintenance of independence, and healthy aging. Despite this, rates of self-directed help seeking are low, as are referral rates from general practice to hearing care. This study aimed to explore the barriers and enablers to general practitioner (GP) referral of adults aged 50+ years to hearing care. Methods A cross-sectional questionnaire was designed using the Theoretical Domains Framework of behaviour change and administered to a self-selected sample of 103 Australian GPs. Results Identified enablers included positive beliefs about the consequences of hearing rehabilitation and experiencing positive role models of hearing care including referral. Contextual issues such as time constraints, costs of hearing care, and limited availability of local audiology resources were the most frequently cited barriers to referral. Content analysis of free-format responses yielded 25 themes in total, eight of which were not previously documented in the published literature. Conclusions GP beliefs about hearing care and the outcomes of referral were generally positive, however, logistical concerns and contextual constraints such as restricted appointment times were prominent barriers to hearing care referral. Identifying the key barriers and enablers to GP referral of older adults to hearing care will facilitate the design of targeted behavioural interventions aimed at increasing referral rates. Further qualitative investigation of the key modifiable barriers and enablers identified in this study is warranted to clarify how best to address these in clinical practice.

INTRODUCTION/ AIMS:Incorporating the perspectives of knowledge-users such as stroke survivors into intervention development processes can enhance their relevance and feasibility. The aims of this study were: i) to use co-design to determine "active ingredients" and develop a personalised physical activity intervention for stroke survivors, and ii) to evaluate the co-design process. METHODS:A four-stage integrated knowledge translation approach (involving planning and workshops) was applied to co-design a post-stroke physical activity intervention. Knowledge-user participants (stroke survivors (n = 10), carers (n = 3) and clinicians (n = 12)) were recruited. Knowledge-user participants (n = 25) and the research team (n = 13) were invited to participate in a survey evaluation of the co-design process. Quantitative survey responses were analysed descriptively. Open-ended responses were grouped and summarised as key findings. RESULTS:Knowledge-users highlighted that flexibility in intervention delivery, consideration of personal preferences, aphasia-friendly resources and ongoing support were important intervention active ingredients. The developed physical activity intervention included a shared decision-making process, programme set-up, ongoing support and resources. High levels of trust, transparency and shared learning in the co-design process were reported by 81% of knowledge-users on project completion. Survey key findings included: 1) Co-design and the lived experience are highly valued by all involved. 2) Output that improves stroke care is important. 3) The co-design workshops provided a respectful atmosphere with opportunity for open discussion. 4) Participation in co-design can be personally beneficial. CONCLUSIONS:Using co-design, active ingredients were identified, and a comprehensive post-stroke physical activity intervention was developed. The co-design process was highly regarded by all and added valuable insights. CONTRIBUTION OF THE PAPER.

ObjectiveTo evaluate changes in quality-of-life and explore psychosocial influences on social participation and recovery in chronic stroke survivors following intensive upper limb neurorehabilitation.DesignMixed-methods design with quantitative (pre-post design with follow-up) and qualitative (semi-structured interview) phases.SettingThree-week Queen Square upper limb neurorehabilitation programme.Participants65 stroke survivors who participated in the programme from July 2016 to March 2018.Main measuresStroke Impact Scale (3.0) (SIS) and Action Research Arm Test, collected on admission, discharge, 6-week and 6-month follow-up (n = 65). Beliefs and psychosocial factors influencing quality-of-life were investigated through thematic analysis of semi-structured interviews in two subgroups, based whether the SIS-participation domain change from admission to follow-up was high (> 20, n = 5) or low (<-24, n = 5).ResultsSeven out of eight SIS domains, overall self-rated recovery (p < 0.001) and Action Research Arm Test (p < 0.001) improved from admission to discharge. The emotion domain improved from admission to discharge (p < 0.001) and reduced from discharge to 6-month follow-up (p < 0.001). Interviews highlighted four key psychosocial themes with contrasting positive and negative perspectives between higher change and lower change groups; themes 'hidden negative effects' and 'loneliness' were evident in the lower change group and 'getting on with my life' in the higher change group.ConclusionThe Queen Square upper limb neurorehabilitation programme led to measurable therapeutic benefits on physical and non-physical quality-of-life outcomes. However, the lack of sustained improvement in self-reported emotion contrasts with the clear benefits in other domains. This indicates a need for ongoing psychosocial support for some stroke survivors, supported by the qualitative findings.

Background Hip osteoarthritis (OA) is a leading cause of chronic pain and disability worldwide. Self-management is vital with education, exercise and weight loss core recommended treatments. However, evidence-practice gaps exist, and service models that increase patient accessibility to clinicians who can support lifestyle management are needed. The primary aim of this study is to determine the effectiveness of a telehealth-delivered clinician-supported exercise and weight loss program ( Better Hip ) on the primary outcomes of hip pain on walking and physical function at 6 months, compared with an information-only control for people with hip OA. Methods A two-arm, parallel-design, superiority pragmatic randomised controlled trial. 212 members from a health insurance fund aged 45 years and over, with painful hip OA will be recruited. Participants will be randomly allocated to receive: i) Better Hip ; or ii) web-based information only (control). Participants randomised to the Better Hip program will have six videoconferencing physiotherapist consultations for education about OA, prescription of individualised home-based strengthening and physical activity programs, behaviour change support, and facilitation of other self-management strategies. Those with a body mass index > 27 kg/m 2 , aged < 80 years and no specific health conditions, will also be offered six videoconferencing dietitian consultations to undertake a weight loss program. Participants in the control group will be provided with similar educational information about managing hip OA via a custom website. All participants will be reassessed at 6 and 12 months. Primary outcomes are hip pain on walking and physical function. Secondary outcomes include measures of pain; hip function; weight; health-related quality of life; physical activity levels; global change in hip problem; willingness to undergo hip replacement surgery; rates of hip replacement; and use of oral pain medications. A health economic evaluation at 12 months will be conducted and reported separately. Discussion Findings will determine whether a telehealth-delivered clinician-supported lifestyle management program including education, exercise/physical activity and, for those with overweight or obesity, weight loss, is more effective than information only in people with hip OA. Results will inform the implementation of such programs to increase access to core recommended treatments. Trial registration Australia New Zealand Clinical Trials Registry ( ACTRN12622000461796).

Background Primary care practitioners worldwide are urged to promote dementia risk reduction as part of preventive care. To facilitate this in Australian primary care, we developed the Umbrella intervention, comprising a waiting room survey and patient information cards for use in consultations. Educational and relational strategies were employed to mitigate implementation barriers. Methods In this cross-sectional, non-randomised implementation study within the South East Melbourne Primary Health Network, we employed mixed-methods outcome evaluation. Antecedent outcomes (acceptability, appropriateness, and feasibility) and actual outcomes (adoption, penetration, and fidelity) were assessed from the perspective of primary care practitioners and patients. Results Five practices piloted the intervention and implementation strategies, including 16 primary care practitioners engaging with 159 patients. The Umbrella intervention was deemed acceptable, appropriate, and feasible, but penetration was limited. Approximately half of eligible primary care practitioners used the intervention, with moderate fidelity. Engagement with implementation strategies was similarly limited. While most strategies were well-received, improvements in online peer discussions and staff readiness were desired. Conclusions The Umbrella intervention is a viable approach to promoting dementia risk reduction in Australian general practice, supported by educational and relational strategies. Stakeholder-informed refinements to enhance uptake are recommended before advancing to a definitive trial.

Background Older people living in residential aged care are vulnerable to infections. High quality infection prevention and control (IPC) practice is therefore vital in this setting. It is important to assess current IPC practice to identify areas where best practice is lacking, and where improvement efforts could most effectively be targeted. The aim of this study was to identify evidence-practice gaps in IPC practice in residential aged care. Methods This study used two scenarios to assess use of a range of standard and transmission-based precautions in residential aged care. Systematic methods were used to design the scenarios. Twenty-seven staff from four residential aged care facilities participated in semi-structured interviews. Participants were presented with the scenarios and asked what IPC actions they would take in everyday practice. Individual and team-based practice was explored. Participants reported practices were then compared to evidence-based practice. Results Results from both scenarios were combined and a total of 11 evidence-practice gaps identified. These included gaps in performing hand hygiene before touching a resident (for example, when helping a resident transfer) and not donning protective eyewear or face shield before taking a nasal/throat swab on the resident with suspected respiratory viral infection. Conclusion The use of scenarios provided a practical and acceptable method to rapidly assess a range of IPC practices among a diverse group of participants. The IPC evidence-practice gaps identified will be used in the next phase of work where barriers to uptake of the identified IPC evidence-practice gaps will be explored.

Nutrition is essential within cancer care, yet patient and carer access to nutrition care and information is variable. This study aimed to (1) investigate patient and carer access and perceptions, and health professional views and practices, relating to cancer nutrition information and care; and (2) co-design interactive resources to support optimal nutrition care. Patients and carers completed a survey regarding access to nutrition care and information. Seven multidisciplinary health service teams were invited to participate in a survey and focus group to assess barriers and enablers in nutrition practices. Focus groups were recorded, transcribed and thematically analyzed. Eligible patients, carers, and health professionals were invited to four virtual workshops utilizing experience-based co-design methods to identify nutrition priority areas and design resources. Workshop participant acceptability of the resources was measured. Of 104 consumer survey respondents (n = 97 patients, n = 7 carers), 61

Background The challenge of implementing evidence into routine clinical practice is well recognised and implementation science offers theories, models and frameworks to promote investigation into delivery of evidence-based care. Embedding implementation researchers into health systems is a novel approach to ensuring research is situated in day-to-day practice dilemmas. To optimise the value of embedded implementation researchers and resources, the aim of this study was to investigate stakeholders’ views on opportunities for implementation science research in a cancer setting that holds potential to impact on care. The research objectives were to: 1) Establish stakeholder and theory informed organisation-level implementation science priorities and 2) Identify and prioritise a test case pilot implementation research project. Methods We undertook a qualitative study using semi-structured interviews. Participants held either a formal leadership role, were research active or a consumer advocate and affiliated with either a specialist cancer hospital or a cancer alliance of ten hospitals. Interview data were summarised and shared with participants prior to undertaking both thematic analysis, to identify priority areas for implementation research, and content analysis, to identify potential pilot implementation research projects. The selected pilot Implementation research project was prioritised using a synthesis of an organisational and implementation prioritisation framework – the organisational priority setting framework and APEASE framework. Results Thirty-one people participated between August 2022 and February 2023. Four themes were identified: 1) Integration of services to address organisational priorities e.g., tackling fragmented services; 2) Application of digital health interventions e.g., identifying the potential benefits of digital health interventions; 3) Identification of potential for implementation research, including deimplementation i.e., discontinuing ineffective or low value care and; 4) Focusing on direct patient engagement e.g., wider consumer awareness of the challenges in delivering cancer care. Six potential pilot implementation research projects were identified and the EMBED project, to support clinicians to refer appropriate patients with cancer for genetic testing, was selected using the synthesised prioritisation framework. Conclusions Using a theory informed and structured approach the alignment between strategic organisational priorities and implementation research priorities can be identified. As a result, the implementation research focus can be placed on activities with the highest potential impact.

Hospitals use many single-use devices that produce more waste and greenhouse gas emissions than reusable devices; operating theatres alone are responsible for up to a third of hospital waste. We explored barriers and enablers to replacing disposable devices with reusable alternatives in operating theatres by use of interviews, the Theoretical Domains Framework, and theory-informed behaviour change techniques. 19 stakeholders were interviewed at a large tertiary hospital in Melbourne, Australia, and 53 barriers and 44 experience-based or intuition-based enablers were identified. 30 strategies were identified across six topics: external purchasing (two strategies); internal purchasing (seven strategies); incentivisation and standardised environmental decision making (three strategies); successful practical introduction of reusable devices (five strategies); identification of goals and facilitation of leadership (two strategies); and a community of practice and knowledge building (11 strategies). We present these 30 implementation strategies, from the individual to the policy level, which consist of evidence-based behaviour change techniques aimed at addressing the identified barriers to replacing single-use devices with reusable alternatives.

There is limited research on the experiences of people in working to embed, integrate and sustain simulation programmes. This interview-based study explored leaders’ experiences of normalising a simulation-based education programme in a teaching hospital. Fourteen known simulation leaders across Australia and North America were interviewed. Semi-structured interviews were analysed using reflexive thematic analysis sensitised by normalisation process theory, an implementation science theory which defines ‘normal’ as something being embedded, integrated and sustained. We used a combined social and experiential constructivist approach. Four themes were generated from the data: (1) Leadership, (2) business startup mindset, (3) poor understanding of simulation undermines normalisation and (4) tension of competing objectives. These themes were interlinked and represented how leaders experienced the process of normalising simulation. There was a focus on the relationships that influence decision-making of simulation leaders and organisational buy-in, such that what started as a discrete programme becomes part of normal hospital operations. The discourse of ‘survival’ was strong, and this indicated that simulation being normal or embedded and sustained was still more a goal than a reality. The concept of being like a ‘business startup’ was regarded as significant as was the feature of leadership and how simulation leaders influenced organisational change. Participants spoke of trying to normalise simulation for patient safety, but there was also a strong sense that they needed to be agile and innovative and that this status is implied when simulation is not yet ‘normal’. Leadership, change management and entrepreneurship in addition to implementation science may all contribute towards understanding how to embed, integrate and sustain simulation in teaching hospitals without losing responsiveness. Further research on how all stakeholders view simulation as a normal part of a teaching hospital is warranted, including simulation participants, quality and safety teams and hospital executives. This study has highlighted that a shared understanding of the purpose and breadth of simulation is a prerequisite for embedding and sustaining simulation. An approach of marketing simulation beyond simulation-based education as a patient safety and systems improvement mindset, not just a technique nor technology, may assist towards simulation being sustainably embedded within teaching hospitals.

Background Mobile health interventions delivered through mobile apps are increasingly used in physiotherapy care. This may be because of the potential of apps to facilitate changes in behavior, which is central to the aims of care delivered by physiotherapists. A benefit of using apps is their ability to incorporate behavior change techniques (BCTs) that can optimize the effectiveness of physiotherapeutic interventions. Research continues to suggest that despite their importance, behavior change strategies are often missing in patient management. Evaluating mobile apps that physiotherapists can use to drive behavior change may inform clinical practice and potentially improve patient outcomes. Examining the quality of apps and exploring their key features that can support behavior change and physiotherapy care are important aspects of such an evaluation. Objective The primary aim of this study was to describe the range of mobile apps in app stores that are intended for use by patients to support physiotherapy care. The secondary aims were to assess app quality, BCTs, and their behavior change potential. Methods A systematic review of mobile apps in app stores was undertaken. The Apple App Store and Google Play were searched using a 2-step search strategy, using terms relevant to the physiotherapy discipline. Strict inclusion and exclusion criteria were applied: apps had to be intended for use by patients and be self-contained (or stand-alone) without the requirement to be used in conjunction with a partner wearable device or another plugin. Included apps were coded for BCTs using the Behavior Change Technique Taxonomy version 1. App quality was assessed using the Mobile App Rating Scale, and the App Behavior Change Scale was used to assess the app’s potential to change behavior. Results In total, 1240 apps were screened, and 35 were included. Of these 35 apps, 22 (63%) were available on both the Apple App Store and Google Play platforms. In total, 24 (69%) were general in their focus (eg, not condition-specific), with the remaining 11 (31%) being more specific (eg, knee rehabilitation and pelvic floor training). The mean app quality score (Mobile App Rating Scale) was 3.7 (SD 0.4) of 5 (range 2.8-4.5). The mean number of BCTs identified per app was 8.5 (SD 3.6). BCTs most frequently included in the apps were instruction on how to perform a behavior (n=32), action planning (n=30), and self-monitoring of behavior (n=28). The mean behavior change potential score (App Behavior Change Scale) was 8.5 (SD 3.1) of 21 (range 3-15). Conclusions Mobile apps available to support patient care received from a physiotherapist are of variable quality. Although they contain some BCTs, the potential for behavior change varied widely across apps. International Registered Report Identifier (IRRID) RR2-10.2196/29047